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Change is right around the corner for payers, providers and health plan members that affect cost-sharing and provider network directories.

One of the most contentious issues in healthcare – surprise billing – reaches a new milestone Jan. 1, 2022 as interim final rules and a clear process for many out-of-network billing goes into effect. Claims generated from out-of-network emergency services, out-of-network services at in-network facilities and air ambulance services must hold members harmless and be adjudicated at the median in-network contracted rate for a geographic area (Qualifying Payment Amount or QPA) within 30 days of receipt. QPA does not apply to those states that have the All-Payer Model or state-mandated fee schedules.  Health plans will need a grasp of various state rules to reach correct formulas for calculating payments, as self-funded plans under ERISA are no longer exempt from state rules which vary greatly. In any case, the more stringent of either state or federal rules in holding consumers harmless applies.

Ground Ambulance Charges a Notable Gap

With the QPA as a starting point, there are remedies through negotiation and independent dispute resolution that will determine what rate will ultimately be paid for a service. The stakes appear high, as that rate established in open negotiation and IDR will become the QPA for the provider and services reviewed for at least 90 days.

HealthRules Payer® may be configured to automatically promote applicable claims to in-network, and enhancements to compare QPA with Non Par and Billed amounts are in development.  Current regulations address known gaps, with an exception for ground ambulance balance billing. Slightly more than half of such rides create out-of-network bills; in some states as many as two-thirds of rides do so. The patchwork of ground ambulance service providers and local laws makes this regulation more complex. A regulatory advisory committee is studying the issue.

Provider Directories Get a Makeover

Another aspect of the No Surprises Act coming into play in 2022 is the provider directory requirement, which governs how up to date online and paper provider directories must be. As part of the “hold harmless” philosophy in which health plan members could inadvertently receive out-of-network services due to inaccurate directory listings, and building upon current provider directory initiatives, plans have new requirements to meet. Online databases must be updated at least every 90 days in a manner that can be audited for compliance and accuracy. The burden is on providers to verify their information if they want to be represented as in-network, but payers also have a responsibility to remove unverified information until certified by the provider.

Plans will have two business days to make online changes; printed directories require a date notation to indicate a publication date. Phone requests to change provider information must be handled within a business day with an auditable process to verify the work is complete. Services rendered based on incorrect information must be processed as in-network.

‘Hold Harmless’ the Watchword

The theme for both sets of regulation is to hold members harmless for costs incurred when they have no option; however, some of the nuances are still to be ironed out and there are court challenges underway as to how the regulations and rules are being interpreted.

In a recent interview, Stephen Krupa spoke with Lucienne Ide, MD, PhD, founder and CEO of Rimidi. Ide’s focus is on patients with chronic diseases. Episodic care is not working for them, she shared, and a once-a-year or once-a-quarter trip to the doctor feels more like being called to the principal’s office than a health-focused partnership.

“We try to keep that focus on empathy for the patient and for the end user and to be sort of obsessive about our customers and our customer experience,” she said. Her previous experience in venture capital convinced her that investors didn’t understand the actual experience of the doctor, the nurse, the patient, for whomever they were building the tech.

At Rimidi, Ide and her team are building sustainable progress by pushing healthcare past just digitizing data into genuine decision-support tools, innovating in care delivery and doing the “dirty work” of truly setting patients up for success. Rimidi provides a suite of solutions to healthcare delivery systems for big health systems and  independent practices, layering decision support on top of the electronic health record. EHRs, Ide notes, are the record of authority and aren’t going away. “But we’ve got to put the tools on top of them that make them usable and efficient,” she says.

Ide has strong opinions about tackling the pain points of shifting to value-based models and what the tech industry needs to build for doctors who only have three minutes to make a decision: “IT systems need to do what humans don’t do very well, which is to aggregate and analyze and curate and present the necessary data in a very efficient manner.”

In this podcast, Ide and Krupa talk about how entrepreneurs should approach their ventures. “I always encourage people at the beginning of the journey, that if you’re not bringing a personal experience to it, or even if you are, continue to listen,” Ide says. “Listen more than you talk.”

Listen to the full conversation here:

About Steve’s Guest

Lucienne Marie Ide founded Rimidi, a cloud-based software platform that enables personalized management of health conditions across populations. She brings diverse experiences in medicine, science, venture capital and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry and society, Lucie left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize the industry.

Have you ever had the unfortunate experience of stepping barefoot on a LEGO®? If you have, your first thought was probably something like AHHH! Not, ‘Wow! What a superb example of a composable architecture building block – with perfectly standardized bricks and studs jabbing me in the foot!’

Wait, why are we talking about LEGO in our technology blog? Well, we recently sat down with the CTOs of our products – Matt Kuntz, Dan Vnuk, & Amlan Dasgupta – to talk about composable architecture. Interestingly, our chat took a turn toward LEGO and Michelangelo’s David.

Why is composable architecture important?

Imagine building the Millennium Falcon out of LEGO versus found materials. The LEGO set comes with perfectly standardized bricks that seamlessly fit together. It’s a breeze to snap the pieces together and in a couple hours your finished product looks exactly like the picture on the box. The ‘found materials’ option is going to take a lot longer and have a less definitive outcome.

If you put yourself in the shoes of the CIO at a health plan – they are responsible for creating an effective tech stack ecosystem. Picture this ecosystem as the Millennium Falcon that needs to be built brick by brick. This ecosystem needs to support their growing business needs while also being easy to maintain. They need to bring solutions built by different companies together and create a seamless, end-to-end workflow. Each element needs to be sewn together, requiring solutions that are interoperable, easily updated, and agile. Composable architecture makes this possible.

Payer solutions leveraging composable architecture have a whole host of benefits that enable superior business outcomes including:

• Increased speed to value
• Implementation ease
• Clearly defined interfaces
• Flexibility to improve functionality
• Adaptability to changing business needs
• Loosely coupled systems for seamless upgrades
• Clear channels of ownership and accountability

What are the challenges of composable architecture?

Composable architecture is great – but there are some significant outcomes if you don’t get it right:

• Lack of transparency – When different systems are cobbled together, there’s a risk of losing transparency. A solution with a successful composable architecture should enable data sharing that increases transparency. Data transparency is important as it enables users to work with data no matter what application or component created it.
• Integrated but not optimized – Picture two systems that work together but weren’t specifically designed to work together. Meaning that yes, the system functions BUT it’s missing out on a world of opportunity to elevate the whole experience with things like data sharing, transparency, and more.

Composable architecture & HealthEdge

At HealthEdge, we are working to build the composable building blocks that enable the end-to-end ecosystem for Payors. Each standalone product, HealthRules Payer®, GuidingCare, and Source, can easily integrate into the various components of a payer’s ecosystem, including each other to create a next-generation integrated solution suite. For example, HealthRules Payer is a core claims admin system with hundreds of applications integrating through APIs – hundreds of applications that are constantly evolving and improving. Our products must be able to grow and evolve with these businesses and applications – we must be able to deliver the best technology, implement it efficiently, keep it running, and continuously update to new functionality. Without composable architecture we’d have a tangled mess of custom code.

When you build composable payer products, you can configure functionality and connections that allow flexibility and confidence in the products. Otherwise, chaos breaks loose during upgrades and things don’t work. You end up configuring whole parts of the workflows with custom workarounds that are difficult to maintain.

As you think about composable architecture and what it means to you and your ecosystem, consider the following:

• Integration capabilities
• Ease of implementation
• Ability to deploy
• Scalability
• Speed of upgrades
• Adaptability to changing needs

LEGO – The composable architecture archetype

Humble, but mighty, these versatile blocks are standardized, have clearly defined integration points, and are infinitely stackable. A veritable ideal example of composable architecture.

You can go to the store and buy thousands of standard Lego blocks. If you are really good, in a few days you can put together something that looks roughly like the Millennium Falcon. It will be blocky, and the color will be off, but everyone will recognize the Millennium Falcon. If you go buy a Millennium Falcon set, all the pieces will be the right color, and there will be lots of custom pieces for things like gun turrets and there will be detailed instructions for how to put it together. It will only take you a few hours, and when you are done, it will really look like the Millennium Falcon. The pieces are still Legos, and you can still attach any other Lego pieces to build something custom, but if what you want is the Millennium Falcon, you will get a better Millennium Falcon than you could get from standard Legos.

The thing with LEGO is that even a stunning compilation of their bricks pales in comparison to Michelangelo’s exquisitely formed David. LEGO, while a wonderful example of composable architecture, is inherently limited by its form. No matter how you put the pieces together, the result will always be a compilation of LEGO.

The Future – Transforming LEGO into masterpieces

The vision our CTOs share of our future technology is to create something so much more than interchangeable blocks. They are on a mission to create individual best-in-class products that integrate and deliver an unmatched experience – while also providing interfaces and building blocks that can easily integrate with non-HealthEdge products. Picture systems linking together and not only seamlessly integrating but having a deep understanding of how the other one works and building on it – creating a sum that is far greater than the parts.

‘Our vision is to develop our suite of products in a way that they do things that no other set of products could. Not by blocking off the APIs. We’ll be open. We’ll be opening our APIs and allowing anybody to integrate, but by designing the products to work well together, we’ll have a set of products that work together better than anybody else’s products.’ – Matt Kuntz, CTO, HealthRules Payor, HealthEdge

We’re excited for that future.

The machinery of the regulatory world grinds forward and compliance deadlines come and go. The ambitious interoperability and transparency regulations that are reshaping key elements of the industry are under continual interpretation and review by HealthEdge staff. We are holding focus groups and facilitating an ongoing dialogue with our customers to stay on top of their concerns and shed light on developments as they occur.

Everyone has more questions than answers right now. The regulatory environment is in a bit of a holding pattern because so many things have been paused, but that doesn’t mean our work to prepare is wasted. We need to stay vigilant but not get ahead of ourselves.

As an example, one focus group participant recently asked us how regulators in a fluid environment will assess whether health plans are complying with Transparency in Coverage Machine Readable Files if records are not included. Regulators want to see a “good faith” effort by health plans. If a record is missed because a reasonable algorithm missed it, the plan has not failed compliance, because they made a good faith effort. But they would be expected to correct this as soon as practical.

We are continuing our technical work as scheduled and encourage plans to stay committed during this time. The additional time will ensure that the “unknowns around the requirements” not yet presented through rulemaking are thoughtfully created, while we stay focused on the enhancements that will assure compliance with the requirements and beyond. The one thing no plan should do is sit back and wait for the pieces to fall into place. If there’s anything that 2020 and 2021 have taught us, it’s to expect the unexpected!

HealthEdge, GuidingCare® and Source® customers who wish to dialogue with HealthEdge as we develop compliant solutions should reach out to their Account Executives. Focus groups are held Thursdays at 11:30 a.m. ET, usually covering a single topic. The No Surprises act is slated for discussion Dec. 2, with Machine Readable Files to be covered Dec. 16. January 2022 topics are in the works.

The journey of transforming healthcare starts with innovation. At HealthEdge, customers can expect transformational business and IT solutions that drive superior business outcomes.

For more than 15 years, HealthEdge has helped customers of all sizes and lines of business transform their organizations, innovate, successfully compete, and achieve breakthrough results.

It all started at the inception of HealthEdge in 2005 with HealthRules Payer®. Our flagship core claims administration solution introduced the unique English-like HealthRules Language®, which transforms the benefit-plan design, network design and contracting process, and makes claims processing faster and easier, while delivering high auto-adjudication rates, high accuracy, and unprecedented transparency. HealthRules is a next-generation platform, recognized by Gartner, KLAS, and other reputable analyst groups.

In 2020, HealthEdge extended its offerings with the acquisition of Source to add claims payment accuracy, pricing, and editing capabilities to our existing offerings. With the acquisition of GuidingCare®, HealthEdge obtained the most successful modern care management platform in the marketplace. This year, we welcome Wellframe and its digital health management capabilities to the family.

Our growth and innovation timeline has led us to serve nearly 100 health plan customers with a combined solution suite that touches over 35 million covered lives across all lines of business. And we’re not stopping anytime soon. Together, HealthRules Payer, Source, GuidingCare, and Wellframe empower customers to effectively compete, improve healthcare quality, and be resilient to changes in the healthcare marketplace. The integrated ecosystem offered by these products moves customers closer to offering a full digital experience to their members.

Looking forward, HealthEdge is focused on three areas of innovation: efficiency in business processes and workflows; increased automation through analytics and machine learning; and creating an application partner ecosystem through API access and data exchange with the HealthEdge application platforms.

We are also committed to a digital-first experience for health plans that complements the composable future-state of the healthcare IT ecosystem. To keep up with digital disruption in the healthcare industry, payers need intelligent, next-generation solutions. Payers who do not invest in next-generation technology will likely be left behind.

As HealthEdge continues to grow, refine our solutions and integrations, and build out partner relationships, health plans can trust that HealthEdge will remain a leading innovation partner with a renewed focus on customer success. I am excited to see where 2022 and the coming years will take us.

If a health plan takes the DIY path, what happens to its knowledge resources over time? In the “build” scenario, an organization owns the product and every challenge that comes with it. If something breaks or becomes obsolete, will the resources to keep it up be available? Will the organization be poised to chase innovation as its competitors are sure to do? Can the plan command the talent in the marketplace to keep its unicorn solution operating at peak value? When development talent and expertise erode, it will mean trouble. The expertise to train users and provide day-to-day technical support is critical to long-term success.

Management should prepare for an ongoing tide of integration requests. Contracting and partnership for these becomes a perpetual administrative function – another cost often overlooked.

As a health plan executive, ask yourself when considering the “buy or build” argument whether there is already a mature solution on the market that will do the job. In healthcare, smart vendors have already developed an interoperability infrastructure necessitated by recent government regulations. Look for this kind of commitment from any vendor in your own industry because it could make buying a solution even easier – it certainly does in the case of healthcare.

Executives should weigh what they hope to gain from building a proprietary solution when the hard work has already been done for them. Will this give them a competitive advantage? Do they have a realistic view of the risk and ROI? Can they invest sufficiently in the initial architecture to build a comprehensive solution?

We are a nation of do-it-yourselfers who take pride in self-sufficiency, but knowing when to tap the real experts is a strength, not a weakness. Remember the adage to “do only what you do best.”

Asking hard and far-reaching questions now will help you avoid Big Fail #5.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.